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A drug could save the lives of premature babies, but pregnant mothers must be encouraged to undergo checks if there appear to be any problems. (Oupa Nkosi)

Extended drug roll-out is good news for prem babies

Phyllis Mbanje, Amy Green
A simple injection could save many lives, but pregnant mothers must be encouraged to undergo checks if there appear to be any problems.

Premature births account for 50% of neonatal (within in the first four weeks of birth) deaths in South Africa, according to a 2012 United Nations report on child mortality.

But a cheap and fairly easy to administer life-saving drug for premature babies has recently gained traction in our public sector institutions, according to Peter Macdonald, a gynaecologist at the University of Pretoria.

"The drugs aren’t new but, up until recently, they have only been available in hospitals. "We have just had them added to the essential drug list and they’re available at community health centres that have midwife units where they do deliveries," he said.

Maturing lungs
The drug, a corticosteroid, speeds up the maturation of the lungs of the baby and is given by injection to pregnant women who are at risk of premature labour when they are six to eight months into their pregnancies, Eckhart Buchmann, from the department of obstetrics and gynaecology at the University of the Witwatersrand, said.

"The corticosteroid commonly used in South Africa is betamethasone, also marketed as Celestone, and is given as two injections of 12mg each, 24 hours apart before delivery," he said.

Ruth Davidge, the co-ordinator for the Neonatal Nursing Association of South Africa, said the corticosteroids were part of the country’s routine guidelines regarding management of preterm labour.

"The health department is focusing on increasing the use of this drug at all levels, along with other interventions. As with most countries, preterm birth and its complications are now the leading cause of under-five mortality," she said.

The challenge is to identify women at risk
However, many women arrive at facilities once they are in advanced premature labour when it is too late to administer the drug, according to a 2009 paper published by the World Health Organisation (WHO), written by Justus Hofmeyer, an obstetric specialist from the East London Hospital Complex.

He said that the major barrier to the implementation of corticosteroid therapy is the difficulty of identifying women at risk of preterm delivery in time to administer corticosteroids, which required "an effective and well-utilised antenatal service".

For this intervention to be successful, Hofmeyer said, both healthcare providers and pregnant women need to be made aware of the option and how to access it. "The information to pregnant women would need to focus on early reporting to a health facility at the first signs of pregnancy complications."

Only 44% of women visit a clinic by 20 weeks into their pregnancy, which is "far from optimal", according to the Health Systems Trust’s latest district health barometer report.

And, as the Medical Research Council’s 2013 saving babies report pointed out, women who never initiated antenatal care, or those who booked late, were most at risk of preterm births.

This was most prominent with the poorest women, who often live in rural areas, and who attend district hospitals that have other administrative challenges like inadequate facilities, the report noted.

Clinics will help overcome social barriers
Buchmann agreed that rural women, who have poor access to health services, "will be less likely to benefit from healthcare interventions like antenatal corticosteroids".

He also said there are underlying social problems for those who avoided healthcare on purpose, such as unwanted pregnancies or being an illegal immigrant.

"What we have done now is get betamethasone into the stock of clinics, small units run by midwives who do normal births, so that they are able to give the betamethasone before they transfer women with premature labour to hospitals," Buchmann said.

He explained how the corticosteroid works. "They stimulate production of surfactant in the lungs. Surfactant is a soapy fluid that helps our lungs to open up and stay open when we breathe in."

He said premature babies have limited surfactant in their lungs and the air pockets in the lungs collapse easily in premature babies resulting in death or breathing problems referred to as "hyaline membrane disease".

However, corticosteroids only work if they are given "when the babies are still inside their mothers’ wombs", according to Buchmann.

"Some pregnant women in premature labour deliver almost immediately after arriving in hospital. Corticosteroids need time to work, preferably at least 24 hours before the woman delivers. That makes it difficult to give the injections to everyone in good time," Buchmann said.

Africa and Asia would be major beneficiaries
Preterm birth is now an urgent global priority for the reduction of child deaths, noted a WHO report published last month.

According to the report, more than one in 10 babies around the world is born too early, adding up to some 15-million births each year: "Complications of prematurity kill around one million children annually."

Marleen Temmerman, the director of WHO’s department of reproductive health and research and co-author of the study, said corticosteroids, each costing less than $1 were particularly important in Africa and Asia, where more than 60% of preterm deliveries occur, and where resources are scarce.

"More than three-quarters of preterm babies born in hospitals could be saved with this cost-effective intervention," she said.

South Africa ranks 24 out of 184 countries for its premature birth rate and it’s neonatal deaths remain high at 19 per 1?000 births compared to other countries, according to data from WHO and United Nations.

Developed countries, such as Japan and the United Kingdom for example, have much lower rates, at one death per 1?000 births and three per 1?000 respectively. Even some developing countries fare better, such as Botswana, which has a neonatal death rate of 11 per 1?000 births.

Petro Kruger, an obstetrician at the Kalafong Hospital in Pretoria, said: "Now our aim is to get these to 100% of mums who give birth prematurely because something as simple as giving these two injections can really alter the life of a baby."

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